antepartal hemorrhage beyond fetal viability Lecture.ppt

lecture note on antepartal hemorrhage beyond fetal viability

1. Antepartum HemorrhageAntepartum Hemorrhage
Presented by:Presented by:
Girma Abraham (Dr)Girma Abraham (Dr)

2. Introduction
•Definition:
Vaginal bleeding which occurs after fetal
viability.
•Incidence:
2 – 6 %.

3. Causes
Placental:
•Abruptio placenta.
•Placenta previa.
Non-placental:
•Vasa previa.
•Bloody show.
•Trauma.
•Uterine rupture.
•Cervicitis.
•Carcinoma.
•Idiopathic.

4. Abruptio Placenta

5. Introduction
•Definition:
It is the separation of the placenta from its site
of implantation before delivery of the fetus.
•Incidence:
1 in 200 deliveries.

6. Risk Factors
•Increased age & parity.
•Hypertensive disorders.
•Preterm ruptured
membranes.
•Multiple gestation.
•Polyhydramnios.
•Smoking.
•Thrombophilia.
•Cocaine use.
•Prior abruption.
•Uterine fibroid.
•Trauma.

7. Types
•Total or partial.
•Concealed or reveiled.

11. Presentation
•Vaginal bleeding.
•Uterine tenderness or back pain.
•Fetal distress.
•High frequency contractions.
•Uterine hypertonus.
•Idiopathic PTL.
•IUFD.

12. Diagnosis
•The diagnosis is primarily clinical, but may be
supported by radiologic, laboratory, or
pathologic findings.
•It is generally obvious in severe cases.
•In milder forms the diagnosis is often made by
exclusion.

13. Diagnosis
The echogenic appearance depends upon the
onset of symptoms:
•Acute hemorrhage is hyperechoic to isoechoic
compared with the placenta.
•Resolving hematomas is hypoechoic within one
week and sonolucent within two weeks.

14. Diagnosis
Laboratory testing is not useful in making the
diagnosis:
•Kleihauer-Betke test: sensitivity 17%.
•CA-125: elevated.
•D-dimer: sensitivity 67, specificity 93%
•Thrombomodulin: sensitivity 88, specificity
77%.
•Hypofibrinogenemia < 200 mg/dL.
•Thrombocytopenia < 100,000/microL.

15. Diagnosis
•Gross examination of the placenta often
reveals a clot and/or depression in the
maternal surface.
•It may be absent with acute abruption.

16. Initial Management
•Stabilization of the maternal
cardiopulmonary status.
•Blood work:
- CBC.
- Coagulation profile.
- Fibrinogen.
- Blood type and Rh.

17. Initial Management
•Large-bore intravenous lines and continuous
fetal monitoring
•Correction of the intravascular fluid deficit
via crystalloid +/- PRBC.
•If the PT and PTT > 1.5x control  2u FFP.
•If the platelet count is < 50,000/microL  6u
plt.

18. Initial Management
•Heparin or other anticoagulants ?
•Tocolysis is generally contraindicated.

•Delivery is the optimal treatment. DIC &
hemorrhage will resolve over 12 hours
when the placenta is removed.

19. Initial Management
Medical treatment of coagulopathy for:
•Marked thrombocytopenia (< 20,000/microL)
•Moderate thrombocytopenia(<50,000/microL)
&serious bleeding or planned cesarean delivery.
•FFP or cryoprecipitate if fibrinogen is <100
mg/dL

20. Mild Abruption
•Expectant management with short term
hospitalization.
•Corticosteroid.
•Tocolysis may be of value in mild cases.

21. Delivery
The mode and timing of delivery depend
upon:
•GA.
•The condition of the fetus.
•The condition of the mother (eg,
hypotension, coagulopathy, hemorrhage).
•The status of the cervix.

22. Delivery
•The term or near term fetus should be
expeditiously delivered.
•Amniotomy with placement of a fetal scalp
electrode.

•Oxytocin may be used to augment uterine
activity.

23. Delivery
•C/S is performed in the presence of a
nonreassuring fetal heart rate pattern & when
delay in delivery will endanger the mother or
fetus.
•It should be done after rapid maternal
hemodynamic and clotting factor
stabilization.

24. Complications
•Maternal:
1.Hypovolemia.
2.DIC.
3.Renal failure.
4.Death.
•Fetal:
1.PTL.
2.PNM.
3.IUGR.
4.IUFD.

25. Placenta Previa

26. Introduction
•Definition:
The presence of placental tissue overlying or
proximate to the internal cervical os after
viability.
•Incidence:
Complicates approximately 1 in 300 pregnancies.

28. Risk Factors
•Increasing parity: incidence 0.2 percent in nulliparas
versus up to 5 percent in grand multiparas.
•Maternal age: incidence 0.03 percent in nulliparous
women aged 20 to 29 versus 0.25 percent in nulliparous
women 40 years of age.
•Number of prior cesarean deliveries incidence 10 percent
after four or more.
•Number of curettages for spontaneous or induced
abortions.

29. Independent Risk Factors
•Maternal smoking
•Residence at higher altitudes
•Male fetus
•Multiple gestation: 3.9 and 2.8 previas per 1000
live twin and singleton births, respectively
•Gestational age: the prevalence of placenta
previa is much higher early in pregnancy than at
term

30. Classification
•Complete placenta previa: The placenta
completely covers the internal os.
•Partial placenta previa: The placental edge does
not completely cover the internal cervical os but
partially covers it.
•Marginal placenta previa: The placenta is
proximate to the internal os.
•Low-lying placenta: in which placental edge lies
within 2 to 3 cm of the internal os. (reference)

31. Clinical Manifestations
•Painless vaginal bleeding occurs in 70 to 80
percent of patients.
•10 to 20 percent present with uterine
contractions associated with bleeding.
•Fewer than 10 percent are incidentally detected
by ultrasound.

32. Associated Conditions
•Malpresentation.
•PPROM.
•Congenital anomalies.
•IUGR.

33. Diagnosis
•The diagnosis is based upon results of ultrasound
examination.
•Clinical findings are used to support the sonographic
diagnosis.
•Placenta previa should be suspected in any woman
beyond 28 weeks of gestation who presents with
painless vaginal bleeding.

34. Transabdominal US
•It has a diagnostic accuracy as high as 95%
in detecting placenta previa, with a false
negative rate of 7%.
•Sagittal, parasagittal and transverse
sonographic views should be obtained.

35. Transabdominal US
•It requires the identification of echogenic
placental tissue overlying or proximate to
the internal cervical os (a distance >2 cm).

36. Transvaginal US
•It has become the gold standard for the
diagnosis of placenta previa.
•It is a safe and effective technique, with
diagnostic accuracy greater than 99 percent.
•The probe does not need to come into contact
with the cervix to provide a clear image.

37. Ultrasound
•Both the transabdominal and transvaginal US
should be used as complementary studies.
•Initial transabdominal examination, with
transvaginal sonography if there is any
ambiguity in the placental position.
•Translabial ultrasound imaging is an alternative technique.

38. Antepartum Management
•Avoidance of coitus and digital cervical
examination.
•Counseling to seek immediate medical attention if
there is any vaginal bleeding.
•Women are also encouraged to avoid exercise,
decrease their activity, and notify the physician of
uterine contractions.
•Serial ultrasound evaluations every two to four
weeks to assess placental location and fetal growth.

39. Acute Care of Symptomatic Placenta
Previa
•Large bore IV access & administration of
crystalloid.
•Type and cross-match for four units of PRBC.
•Transfuse to maintain a Hct of 30% if the patient is
actively bleeding.
•Maternal pulse and blood pressure every 15 minutes
to 1 hour depending upon the degree of blood loss.

40. Acute Care of Symptomatic Placenta
Previa
•The fetal heart rate is continuously monitored.
•Quantitative monitoring of vaginal blood loss.
•The source of the vaginal blood (maternal versus
fetal) is intermittently assessed by either an Apt
test or Kleihauer-Betke analysis.
•Urine output is evaluated hourly with a Foley
catheter & should be at least 30 mL/hour.

41. Acute Care of Symptomatic Placenta
Previa
•Hb & Hct.
•Serum electrolytes and indices of renal
function.
•Coagulation profile (fibrinogen, Plt, PT & PTT)
are checked especially if there is a suspicion of
coexistent abruption.

42. Delivery
•Tocolysis is not administered to actively
bleeding patients.
•Delivery is indicated if:
 
         (1) there is a nonreassuring fetal heart
rate.

        
(2) life threatening refractory maternal
hemorrhage.

43. Mode of Delivery
•Cesarean delivery is the delivery route of choice.
•Vaginal delivery may be considered in the presence of:
1.a fetal demise
2.previable fetus
3.some cases of marginal previa, as long as the mother
remains hemodynamically stable.

44. Conservative Management of Stable
Preterm Patients
•The patient is hospitalized at bedrest with bathroom
privileges.
• Stool softeners and a high-fiber diet help to minimize
constipation and avoid excess straining.
•Periodic assessment of the maternal hematocrit.
•Ferrous gluconate supplements (300 mg orally three or four
times per day) are given with vitamin C to improve
intestinal iron absorption.

45. Conservative Management of Stable
Preterm Patients
•Cross match to provide two to four units of
packed red blood cells.
•Prophylactic transfusions to maintain the
maternal hematocrit above 30 percent in
stable asymptomatic patients in anticipation
of future blood loss.

46. Conservative Management of Stable
Preterm Patients
•A single course of corticosteroid between 28 and
34 w.
•Rh(D)-negative women should receive Rh(D)-
immune globulin if they bled.
•Readministration is not necessary if delivery or
rebleeding occurs within three weeks, unless a
large fetomaternal hemorrhage is detected by KBT.

47. Conservative Management of Stable
Preterm Patients
•Fetal growth, amniotic fluid volume, and
placental location are evaluated
sonographically every two to four weeks.
•Tocolysis may be safely utilized if
contractions are present and delivery is not
otherwise mandated by the maternal or fetal
condition.

48. Conservative Management of Stable
Preterm Patients
•Amniocentesis can be done at 36 weeks to
assess pulmonary maturity.
•Scheduled abdominal delivery is suggested
@ 37w or upon confirmation of pulmonary
maturity.

49. Delivery
•Abdominal delivery.
•Two to four units of PRBC should be available for
the delivery.
•Appropriate surgical instruments for performance of
a cesarean hysterectomy should also be available
since there is a 5 to 10 percent risk of placenta
accreta.

50. C/S
•The surgeon should try to avoid disrupting
the placenta when entering the uterus.
•If the placenta is encountered upon opening
the uterus then it is necessery to cut through
the placental tissue to deliver the fetus.

51. Outpatient Managaement
•Women who have never bled.
•Women with placenta previa if bleeding has
stopped for more than one week.
•There are no other pregnancy complications,
such as fetal growth restriction.

52. Outpatient Management
•Live within 15 minutes of the hospital.
•Have an adult companion available 24 hours a day
who can immediately transport the woman to the
hospital if there is light bleeding or call an
ambulance for severe bleeding.
•Be reliable and able to maintain bed rest at home.
•Understand the risks entailed by outpatient
management.

53. Outcome
The maternal and perinatal mortality rates in
pregnancies complicated by placenta previa have
been reduced over the past few decades because of:
•The introduction of conservative obstetrical
management.
•The liberal use of cesarean rather than vaginal
delivery.
•Improved neonatal care.

54. Vasa Previa

55. Introduction
•Vasa previa refers to vessels that traverse the
membranes in the lower uterine segment in advance
of the fetal head.
•Rupture of these vessels can occur with or without
rupture of the membranes and result in fetal
exsanguination.
•The incidence is 1 in 2000 – 3000 deliveries.

56. Associated Conditions
•Low-lying placenta.
•Bilobed placenta.
•Multi-lobed placenta.
•Succenturiate-lobed placenta.
•Multiple pregnancies.
•Pregnancies resulting from IVF.

57. Diagnosis
•The diagnosis of vasa previa is considered if vaginal
bleeding occurs upon rupture of the membranes.
•Concomitant fetal heart rate abnormalities,
particularly a sinusoidal pattern.
•Ideally, vasa previa is diagnosed antenatally by US
with color flow Doppler.

58. Antenatal Management
•Consider hospitalization in the third trimester to
provide proximity to facilities for emergency
cesarean delivery.
•Fetal surveillance to detect compression of vessels.
•Antenatal corticosteroids to promote lung maturity.
•Elective cesarean delivery at 35 to 36 weeks of
gestation.

59. Antepartum Management
•Immediate C/S.
•Avoid amniotomy as the risk of fetal
mortality is 60-70% with rupture of the
membranes.

60. THANK YOU